Adverse Childhood Experiences (ACEs) and Trauma-Informed Practice

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ACEs and Trauma-Informed Practice

Adverse Childhood Experiences (ACE) describe a wide range of stressful or traumatic experiences that can occur from conception to the age of 18 – they include abuse, neglect, and household dysfunction.

It is important to sit this alongside societal issues, so we refer to a pair of ACEs to include Adverse Community Environments like poverty, discrimination, poor housing, lack of economic opportunity and social connectedness. the impact of Covid-19 has been a trauma for all of us and has exacerbated existing inequalities.

Adverse Childhood Experiences (ACE) refer to some of the most intensive and frequently occurring sources of stress that children may suffer early in life.

When children are exposed to adverse and stressful experiences, it can have a long-lasting impact on their ability to think, interact with others and on their learning.

It has been shown that considerable and prolonged stress in childhood has life-long consequences for a person’s health and well-being, with negative behaviours often being used unconsciously as protective solutions to unrecognised problems dating back to childhood.

Work across the country aims to both prevent ACEs occurring in the first place wherever possible, and to prevent the consequences of ACEs in those that have already experienced them.

ACEs can be prevented – research has found that a relationship with one trusted adult during childhood can mitigate the impacts of ACEs on mental and physical well-being.

The Manchester Approach

In Manchester we have an ambition to be an ACE-aware, trauma informed and trauma responsive city. A city with a coordinated approach to reducing exposure to ACEs, where all practitioners work with residents to prevent or mitigate the consequences of trauma; helping children, families, and communities to build resilience; and improve outcomes for residents by working in a trauma responsive way.

The ACEs and trauma informed work is embedded into mainstream provision within the Population Health team; included in the city-wide Covid recovery plan, and is one of the key principles of the Manchester Safeguarding Partnership.

ACEs and trauma informed training is being delivered across the City; and the team are working with organisations and sectors to implement the learning into their core practice.

Further information

To find out more and get involved in this movement contact Gareth Nixon, Programme Lead at gareth.nixon@manchester.gov.uk

What is an Adverse Childhood Experience (ACE)?

The term ACE is used to describe a wide range of stressful or traumatic experiences that children can be exposed to whilst growing up. ACEs range from experiences that directly harm a child (such as suffering physical, verbal or sexual abuse, and physical or emotional neglect) to those that affect the environment in which a child grows up (including parental separation, domestic violence, mental illness, alcohol abuse, drug use or incarceration).

The Commons Select Committee report: Evidence-based early years intervention published in November 2018 cited that whilst there is no universally agreed definition of an adverse childhood experience (ACE) studies addressing the issue have mostly converged on a similar set of experiences falling under this term and listed the following experiences:

verbal abuse
physical abuse
sexual abuse
physical neglect
emotional neglect
parental separation
household mental illness
household domestic violence
household alcohol abuse
household drug abuse
incarceration of a household member.

The Science behind ACEs

When children are exposed to adverse and stressful experiences, it can have a long-lasting impact on their ability to think, interact with others and on their learning. The ‘fight, flight or freeze’ response floods the brain with corticotrophin-releasing hormones (CRH), which usually forms part of a normal and protective response that subsides once the stressful situation passes.

However, when repeatedly exposed to ACEs, CRH is continually produced by the brain, which results in a child remaining permanently in this heightened state of alert and unable to return to their natural relaxed and recovered state. Consequently, children and young people who are exposed to ACEs have increased – and sustained – levels of stress. In this heightened neurological state, a young person is unable to think rationally and finds it impossible to learn.

There is now a great deal of research demonstrating that ACEs can negatively affect lifelong mental and physical health by disrupting brain and organ development and by damaging the body’s system for defending against diseases. Negative behaviours are often used unconsciously as protective solutions to unrecognised problems dating back to childhood thus leading to harmful behaviours, social issues and health problems in adulthood.

Prevalence of ACEs

It is more common to have a few or several ACEs rather than just one. Over 12% of participants in the original US study scored four or higher

There is a dose response relationship between ACEs and the development of poor physical, mental, and behavioural health.

UK studies showed:

Wales – almost 50% experienced 1 ACE and 14% experienced 4 or more
England – almost 50% experienced 1 ACE and over 8% 4 or more
Scotland does not have an ACE survey but it is proposed a similar prevalence of ACEs can be assumed.

The evidence for the Commons Select Committee report cited:

50% of Welsh adults had experienced at least one ACE
47% of English adults had experienced at least one ACE
Scottish Public Health estimated that prevalence in Scotland would be at least as high.

The Children’s Commissioner’s Office estimated at least 690,000 children aged 0–5 in England live in a household with an adult that experienced domestic violence and abuse, substance misuse or mental health issues.

The Pair of ACEs and Inequality

It is important to sit Adverse Childhood Experiences alongside societal issues, so we refer to a pair of ACEs – insert infographic (see attached slide)

The impact of Covid-19 has been a trauma for all of us and has exacerbated existing inequalities.

Poverty in Manchester is a huge challenge and continues to have a significant impact on the life and outcomes of too many of the city’s residents. This challenge is reflected in the number of children living in poverty with the End Child Poverty Coalition estimating that around 46,700 children (42%) in Manchester were living in poverty at the end of March 2020.

Ethnic minority groups faced disparities long before the onset of the pandemic. In GM all Black, Asian and minority ethnic groups have been found to be less likely to be employed pre-COVID-19 than White people. In addition to this people of Pakistani and Bangladeshi ethnic backgrounds (particularly women) have the lowest levels of employment in GM2 .

Poor quality and unaffordable housing remain a critical health equity issue in Manchester.

By addressing adversity in society communities are less likely to experience chronic stress and more likely to have their basic needs met; thus, resulting in lowered adverse childhood experiences and increased resilience.

Manchester is a local authority with extremely high levels of deprivation and has some of the poorest health outcomes in the Country. Comparing local indicators with national data, the health and wellbeing of children in Manchester is worse than England e.g. Life Expectancy at birth (2017-19) is 76.4 years for boys and 80.3 for girls, compared to the national average of 79.8 and 83.4 respectively

(Public Health England – Child Health Profile Manchester March 2021)

We have England’s highest premature (under 75’s) death rates from heart and circulatory disease. Our population is 3x more likely to die from cardiovascular disease (CVD) compared with people in areas with the lowest average deprivation. We also have high prevalence of smoking-related airways diseases and areas with very high neonatal mortality rates.

Experiencing 4 or more ACEs is associated with significantly increased risk for 7 out of 10 leading causes of death in adulthood: heart disease, stroke, cancer, COPD, diabetes, Alzheimer’s, and suicide.

What we are doing in Manchester

Arts

Delivering the Art of Resilience with Manchester Art Gallery with 12 primary schools
Piloting innovative approaches with MADE partners

Criminal Justice

Working with Youth Justice to create trauma informed environments
Produced a Life After Lockdown report highlighted the voice of young people and recommending future support
Trained 400+ frontline officers in trauma informed approaches

Domestic Abuse and Violence

We are facilitating delivery of the Healing Together programme that supports children impacted by domestic abuse. Delivery partners are 4CT, Big Manchester, Catalyst Psychology, Children’s Society, Early Break Manchester Women’s Aid, Thrive Manchester and the Wise Owl Trust
The ACEs/trauma programme lead is a White Ribbon Ambassador for Manchester Public Health

Early Years

Refresh training for all Early Help staff
Health Visitors using strength-based conversations in core practice
During Infant Mental Health week (June 22) we showcased good practice from Spoons, CAPs, Vulnerable Babies team. Manchester Mind, Dad Matters and Big Manchester
Presented to the Manchester Medical Society Paediatrics section

Education

Deliver training each term through the Healthy Schools Behind the Behaviour programme
Staff in 15 schools have completed, or are undertaking, the Trauma Informed UK Schools Diploma in Trauma and Mental Health. These staff have formed a community of practice to share learning
We are working with a number of Trusts to support their schools to implement trauma informed approaches – these include Big Life Schools, Bright Futures, the Co-op Academy, Oasis Community Learning, Wise Owl Trust and Wythenshawe Catholic Academies.

Housing

Following widespread training we have a community of practice led by Northwards Housing that consists of 10 registered housing providers. The group will co-deliver training and share case studies
Southway Housing are incorporating the trauma training into their specialist training on hoarding

Neighbourhoods

4CT have been commissioned to support the voluntary sector in North Manchester to implement trauma informed and trauma responsive approaches. The project – that runs from May 22 to Dec 23 – will also engage with residents and provide key messages about attachment and protective factors. The work is focused on the following neighbourhoods – Ancoats, Clayton & Bradford; Cheetham & Crumpsall; and Miles Platting & Newton Heath
Through the MCC and MLCO neighbourhood teams we are rolling out locality-based training and are starting a pilot in Central to explore the impact of trauma informed approaches in a locality
We are working with Wythenshawe Community Housing and their partners to test approaches that will support residents to build a resilient community
Five community hubs have been established in Blackley, Cheetham, Clayton, Gorton and Wythenshawe. Led by a volunteer sector organisation and/or a school the hubs offer safe spaces where residents can connect and engage in positive activities that mitigate against trauma and promote physical and mental wellbeing. Residents will also be able to access services to support with housing, debt advice, fuel and food poverty etc

Primary Care

Working with West Gorton Medical Centre to develop a trauma informed and trauma responsive practice
Involved in a Violence Reduction Unit pilot with primary care to identify young people who have experienced/or may be exposed to serious youth violence, and how they can be supported.

Voluntary Sector

We are innovating and testing new approaches to being trauma informed and trauma responsive. Examples include: –

– production of video content with 84 Youth and Odd Arts to explore community-based violence and trauma

– delivery of trauma informed yoga sessions and other mindfulness practice at the Resonance Centre, Clayton

– De Paul is using physical activity and creativity to provide social connection and build resilience in the young people they work with

Training

We deliver training to whole staff groups and on a multi-agency basis. Since the start of 2021 over 2,200 individuals have attended our foundational training on ACEs and trauma informed practice.

We have trainers from social work, youth justice, health visiting, housing, arts and the voluntary sector who deliver training and advocate trauma responsive approaches across the system

Working in a Trauma Informed Way

There are several ways that we can apply a trauma informed lens to practice

Look ‘behind the behaviours’ and consider what the root cause of the presenting behaviour may be
Always have a focus on ‘what happened to someone?’ instead of ‘what’s wrong with them?’
Consider how to apply the core principles of a trauma-informed approach
Safety
Trustworthiness & transparency
Peer support
Collaboration & mutuality
Empowerment & choice
Cultural, historical & gender issues

Keep in mind the 4 R’s of trauma informed practice

Realise the widespread impact of trauma and the potential pathways to recovery
Recognise the signs and symptoms of trauma
Respond by integrating our knowledge into practice, policies and procedures
Resist re-traumatisation

Intergenerational Trauma

Please watch our interview with Reviewer, Sarah Newsom, on the research she did on Intergenerational Trauma